Inspection visit
Health inspection
30 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 30 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds in accordance with State law and closed accounts upon discharge in a timely manner for one out of two sampled records (Closed Resident Record CR984).
Residents Affected - Few
Findings include: The facility Resident personal funds policy last reviewed 12/9/24, indicated that upon discharge, eviction or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds. Review of Closed Resident Record CR984's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR984's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 10/8/24, indicated he had diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and schizophrenia (a type of mental condition involving a breakdown in the relation between thought, emotion, and behavior leading to a faulty perception inappropriate action and feelings, withdrawal from reality and personal relationships into fantasy and delusion). These diagnoses were the most recent upon review. Review of Closed Resident Record CR984's clinical nurse progress note dated 11/7/24, indicated that he was discharged from facility at 10:00am. in a private vehicle. Medication reviewed with resident along with doctors appointments. Spoke with sister and she stated she would meet him at his new apartment. Review of facility trust fund account (account with current account open with facility resident funds) dated 4/17/25, indicated that Closed Resident Record CR984 still had an open account with a balance of $41.02. During an interview on 4/17/25, at 11:39 a.m. the Regional Business Office Manager Employee E30 confirmed that the facility failed to convey resident funds in accordance with State law and closed accounts upon discharge for Closed Resident Record CR984 as required. 28 Pa. Code 211.5(d) Clinical records.
Page 1 of 60
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395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0584
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Based on facility policy review, observations, resident council group interview, resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of two shower rooms (One-West), one clean utility room (One-East) and four out of five resident rooms (Resident R22, R46, R61, and Resident R63) and the facility failed to maintain an adequate supply the following day of wash clothes, towels, and blankets readily available for two of two nursing units.
Findings include: The facility Safe and homelike environment policy reviewed 12/9/24, indicated that the facility will provide a safe, clean, comfortable and homelike environment. During a tour on 4/15/25, at 9:30 a.m. the following was observed in the clean utility room on One-East with the Director of Maintenance/ Housekeeping Employee E13: - the ice machine water outlet was observed with brown substance on water outlet. PC-piping behind the ice machine was found with black spotted substance on PC-piping leading to the drain. During an interview on 4/15/25, at 9:31 a.m. the Director of Maintenance/ Housekeeping Employee E13 stated: tubing been here since I've been working here and confirmed the facility failed to maintain a clean, homelike environment in the clean utility room. During an interview on 4/15/25, at 11:00 a.m. three of six residents stated the their bathroom soap dispensers were broken. During observations on 4/16/25, the following was observed: at 9:50 a.m. Resident R61 bathroom was observed with a broken soap dispenser. at 9:51 a.m. Resident R22 bathroom was observed with a broken soap dispenser. at 9:52 a.m. Resident R46 was found with long brown stain on bedside curtain. at 9:56 a.m. Resident R63 bathroom was observed with a broken soap dispenser. During an interview on 4/16/25, at 10:01 a.m. the Director of Maintenance/ Housekeeping Employee E13 confirmed that the facility failed to the facility failed to maintain a safe, clean, and home-like environment for Residents R22, R46, R61, and Resident R63. During observations on 4/17/25, the following was observed: at 10:04 a.m Resident R278 was heard yelling in hall someone please clean the shower room. I can't even take a shower. at 10:06 a.m. the One-West shower room was found with brown substance in small trash can. A horrendous odor was emitting from the trash can and the bathroom. No staff were found cleaning the area.
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Page 2 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0584
During an interview on 4/17/25, at 1:34 p.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to maintain a safe, clean, and home-like environment as required.
Level of Harm - Minimal harm or potential for actual harm
Observations on the first and second nursing units linen carts revealed the following:
Residents Affected - Some
04/15/25 10:10 AM observation of clean linen - 3 gowns, 7 flat sheet s, 5 fitted, 3 blankets. 2nd floor -04/15/25 10:12 AM low side of 2nd floor - approx 10 gowns, 7 flat sheets, 5 fitted, 6 pillow cases, 4 blankets - Hoyer lift. 4/16/25 11:39 a.m. on first floor nursing unit - 14 gowns. 04/16/25 11:43 AM on 2nd floor - 11 gowns /4 loose sheets/ 3 fitted sheets sweet shirt and pajama bottoms / 1 heavy blanket / 1 pad /1 tennis shoes. 04/16/25 11:47 AM 15 gowns/ 10 loose sheets/ 6 blankets heavy/ 5 fitted/ 2 Hoyer lift / 2 pads. On both days of observations - no wash clothes or towels were observed on the linen carts, and limited heavy blankets were found on linen carts during observations. During observations in Director of Maintenance Employee E13 confirmed that the facility did not have enough linen supplies of wash clothes, towels, and heavy blankets. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management
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Page 3 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility provided documents, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate to rule out potential neglect for two of four residents (Resident R23 and R24).
Residents Affected - Few
Findings include: Review of facility policy Abuse, Neglect, Mistreatment Education last reviewed 12/9/24, indicated that the facility prohibits the mistreatment and neglect of residents. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident neglect and mistreatment. Neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator and Director of Nursing are responsible for investigating and reporting incidents of neglect. Upon receiving an incident or suspected incident of abuse or neglect, the Administrator/DON/designees will conduct an investigation to include interviews of any witnesses, the resident, the attending physician, and staff members (on all shifts) having contact with the resident during the period of the alleged incident. Review of the clinical record revealed that Resident R23 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/25, indicated diagnoses of high blood pressure, peripheral vascular disease, and diabetes. Review of Resident R23's physician order dated 4/12/25, indicated to cleanse the vascular wound on the left shin with normal saline, pat dry, apply collagen (used to stimulate new tissue growth), calcium alginate highly absorbent dressings ideal for wounds with moderate to heavy exudate) to wound bed, cover with gauze island dressing daily and as needed. May cover with abdominal pad (pas that absorb fluid and create a moisture barrier for wounds) and wrap with kerlix (gauze bandage roll) if island dressing will not stick, every day shift for peripheral vascular disease. Review of Resident R23's April 2025 Treatment Administration Record (TAR) revealed Resident R23's left shin wound was changed as ordered on 4/13/25, 4/14/25, and 4/15/25. During an observation on 4/15/25, at 11:40 a.m. Resident R23 left lower leg wound dressing was dated 4/12/25. Resident R23 indicated staff were notified it needed to be changed. During an interview on 4/15/25, at 11:41 a.m. LPN, Employee E6 confirmed Resident R23's left lower leg wound dressing was not changed as ordered and dated 4/12/25. During an interview on 4/15/25, at 11:47 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to change Resident R23's wound dressing as ordered. The NHA indicated an investigation will be completed. Review of Resident R23's neglect investigation on 4/17/25, at 9:39 a.m. failed to include witness statements from staff who signed of the resident's dressing change was completed as ordered on 4/13/25, 4/14/25, and 4/15/25.
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Page 4 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0610
Review of the clinical record revealed that Resident R24 was admitted to the facility 2/21/25.
Level of Harm - Minimal harm or potential for actual harm
Review of Resident 24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/4/25, indicated diagnoses sepsis (condition that occurs when the body's immune system has an extreme response to an infection, leading to inflammation that can damage its own tissues and organs), hydrocephalus (buildup of fluid in the brain ventricles that can damage brain tissue and cause various symptoms), and seizures.
Residents Affected - Few
Review of clinical record progress note dated 3/15/25, at 3:46 a.m., revealed a Nurse Aide (NA) reported to nurse that Resident R24 was crawling around on the floor in a puddle of blood behind roommates bed. Assessment found an open cut above right eye that is heavily bleeding. Unsure what resident hit her head on. Resident R24 sent to the hospital, message left for daughter, physician notified. Review of facility submitted documents dated 3/17/25, indicated that a NA reported to unit nurse that Resident R24 was crawling around floor in a puddle of blood behind roommate's bed. Resident R24 was assessed and had an open cut above right eye that was heavily bleeding. First aid was provided. Call placed to 911, resident being sent to hospital for evaluation. Review of facility provided investigation on 4/17/25, at 8:30 a.m., failed to include signed and dated witness statements from the resident's roommate and/or all staff members who had contact with the resident during the shift incident occurred. During an interview on 4/17/25, at 9:44 a.m., the Director of Nursing (DON) confirmed that Resident R24's incident investigation failed to include witness statements to rule out potential neglect. During an interview on 4/17/25, at 3:17 p.m., the Nursing Home Administrator (NHA) confirmed the facility failed to thoroughly investigate potential neglect for two of four residents (Resident R23 and R24). 28 Pa. Code: 201.14(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(2)(e)(1) Management. 28 Pa. Code: 201.19 Personnel policies and procedures. 28 Pa. Code: 201.20(a)(b)(c)(d) Staff development. 28 Pa. Code: 201.29(a)(c)(d)(j)(m) Resident rights.
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Page 5 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0620
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, admissions documentation, billing documents, resident and staff interviews it was determined that the facility failed to maintain admission documentation for two of four sampled residents (Resident R32 and Resident R57) and failed to provide a comprehensive review of resident admission rights, policies, and payment requirements for two of four residents (Resident R62 and R66).
Findings include: The facility Resident rights policy reviewed 12/9/24, indicated that the facility will inform the resident both orally and in writing of his or her rights and regulations governing resident conduct and responsibilities during the stay in the facility. Review of Resident R32's admission record indicated she was admitted on [DATE]. Review of Resident R32's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 4/6/25, indicated she had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), muscle weakness and depression (a state of sadness and loss of interest interfering in daily life activities). Section C0200 BIMS (Brief interview for mental status) revealed that Resident R32 s BIMS score of 12 which indicated that she was cognitively intact. Review of Resident R32's nurse admission assessment dated [DATE], indicated she was fully alert and oriented. Review of Resident R32's clinical record did not include her admissions records. Review of Resident R57's admission record indicated he was admitted on [DATE]. Review of Resident R57's MDS assessment dated [DATE], indicted that he had diagnoses that included heart failure, diabetes, and hyperlipidemia (elevated lipid levels within the blood). These diagnoses were the most recent upon review. Review of Resident R57's clinical notes indicated that family was involved with his care. Review of Resident R57's clinical record did not include signed admissions records. Further review of Resident R32 and Resident R57's documentation did not include an admissions packet or discussion upon admission that included patient portion liability, the daily rate cost structure, resident rights, representative/resident appeal rights, consent to receive treatment, Medicare process, Medicaid process, right to choose ancillary services, bed hold policy, and the consequences for failure to pay. Review of Resident R62's admission record indicated he was originally admitted [DATE]. Review of Resident R62's MDS assessment dated [DATE], indicated he had diagnoses that included
395666
Page 6 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0620
Level of Harm - Minimal harm or potential for actual harm
schizophrenia (a type of mental condition involving a breakdown in the relation between thought, emotion, and behavior leading to a faulty perception inappropriate action and feelings, withdrawal from reality and personal relationships into fantasy and delusion), general weakness and abnormal gait. Review of Resident R66's admission record indicated he was originally admitted on [DATE].
Residents Affected - Few Review of Resident R66's MDS assessment dated [DATE], indicated he had diagnoses that included diabetes, peripheral vascular disease (a progressive narrowing of the blood vessels impacting blood flow to the limbs), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). Review of the facility admissions packet information (documents completed upon admission) did not include per diem cost for resident stay, Medicaid pending portion payment information, or a description of fees for services. Review of facility billing documents indicated that Resident R62 had a Medicaid pending portion bill for $2000, and Resident R66 had a bill for Medicaid pending portion of $5000. During an interview on 4/16/25, at 11:05 a.m. the Regional Business Office Manager Employee E30 stated: If a residents comes in Medicaid pending or they are an insurance cut and apply for Medicaid, our office will try to find out their income. If family is doing it, they might not know the income. We have a default amount we bill at $1000 per month known as the Medicaid pending pay rate. The facility billing company determined the rate. Families may get the bill for $1000, but for some people that is over. We let them know that we look at income, and resident may get $60. If the family or resident happen to know the income, and we found out that amount and the bill is not adjusted and the facility is paid the difference. We have an Medicaid estimate paper. Medicaid pending rate is not in the admissions packet. Its has been like that since the facility was bought. The facility can credit the bill and adjust it and we only use the resident's money to bill. We do not ask the family to use their money to pay the bill. It is not written anywhere. We do this at all four of our facilities. During an interview on 4/17/25, at 9:02 a.m. Resident R66 stated the following: I've been here since July 2024. I was involved in a car accident, went to the hospital and had surgery. I do not know anything about a Medicaid pending bill. I didn't receive any bills. I'm on a Medicaid insurance plan. They did not review any payment responsibility or payment/bill schedule with me. During an interview on 4/17/25, at 9:16 a.m. Resident R62 stated the following: I was admitted around September 2024. My family and wife visit me. My insurance pays for my stay. I have not gotten any bills while I was here. I think I signed admissions paper work but no one reviewed what I had to pay. During an interview on 4/17/25, at 10:29 a.m. the facility Admissions Coordinator Employee E9 she does not reviews admission packet with resident as she works from home and does the insurance. She stated she was the only admissions staff. She stated she did not know what Medicaid pending portion bill was and she hands that off to the financial department. If the resident is Medicaid pending, she reaches out to the financial department and they run a financial screen and we go from there for the approval. She stated she has not seen the admissions packet and that the Nursing Home Administrator should be asked about reviewing admissions with residents.
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Page 7 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0620
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
During an interview on 4/17/25, at 10:59 a.m. the Registered Nurse (RN) Employee E10 confirmed that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for Resident R32 and Resident R57 as required. During an interview on 4/17/25, at 1:34 p.m. information disseminated to the Nursing Home Administrator (NHA) facility the facility failed to maintain admission documentation for two of two sampled residents (Resident R32 and Resident R57) and failed to provide a comprehensive review of resident admission rights, policies, and payment requirements for two of two residents (Resident R62 and R66) as required. 28 Pa Code: 201.18 (b)(2) Management. 28 Pa Code: 201.24 (a) admission policy. 28 Pa Code: 201.19 (i) Resident rights.
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Page 8 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0622
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, resident records and staff interview, the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of three residents sampled with facility-initiated transfers (Resident R47 and R76). Finding include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R47's progress note dated 3/17/25, indicated the resident was heard making grunting noises from his room at 3:25 a.m. The resident was sitting upright at his bedside pointing to his chest and throat, unable to speak. The resident's blood pressure was elevated, had a right sided facial droop, left arm weakness, fatigues, unstable gait, and light headedness. The nurse called 911 and the resident was transferred out to the hospital. Review of Resident R47's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R47's progress note dated 3/17/25, at 11:01 a.m. revealed staff received a call from the hospital treating the resident and inquired about the resident's baseline. Review of the clinical record indicated Resident R76 was admitted to the facility on [DATE]. Review of Resident R76's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and dementia. Review of Resident R76's clinical record revealed that the resident was transferred to the hospital on 1/16/25 and did not return to the facility. Review of Resident R76's progress note dated 1/16/25, at 7:07p.m. revealed the resident continued to have elevated blood pressure and now complaining of a headache. It was indicated the on call provider was called again, and ordered the resident to be transferred to the hospital. Review of Resident R76's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
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Page 9 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0622
Level of Harm - Minimal harm or potential for actual harm
During an interview on 4/17/25, at 11:07 a.m. the Nursing Home Administrator confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer for two out of three residents sampled with facility-initiated transfers (Residents R47 and R76).
Residents Affected - Few
28 Pa. Code 201.29 (a)(c.3)(2) Resident rights.
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Page 10 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0623
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of two residents (Resident R47, and R76).
Findings Include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R47's clinical record revealed that the resident was transferred to the hospital on 3/17/25, and returned to the facility on 3/20/25. A review of Resident R47's clinical record indicated the facility failed to include documented evidence that the facility provided a copy of the written notice that includes the reason for the transfer to the Office of Long-Term Care Ombudsman for the hospitalization on 3/17/25. Review of Resident R76's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of high blood pressure, depression, and dementia. Review of Resident R76's clinical record revealed that the resident was transferred to the hospital on 1/16/25 and did not return to the facility. A review of Resident R76's clinical record indicated the facility failed to include documented evidence that the facility provided a copy of the written notice that includes the reason for the transfer to the Office of Long-Term Care Ombudsman for the hospitalization on 1/16/25. During an interview on 4/17/25, at 11:07 a.m. information disseminated to the Nursing Home Administrator, regarding the notice to a representative of the Office of the Long-Term Care Ombudsman Division was not provided for two of two residents (Resident R47 and R76). 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.
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Page 11 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0625
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide evidence that a written notification of the facility bed hold policy was provided to the resident upon transfer to the hospital for two of two residents (Resident R47 and R76).
Findings Include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R47's clinical record revealed that the resident was transferred to the hospital on 3/17/25, and returned to the facility on 3/20/25. A review of Resident R47's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/17/25. Review of Resident R76's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of high blood pressure, depression, and dementia. Review of Resident R76's clinical record revealed that the resident was transferred to the hospital on 1/16/25 and did not return to the facility. A review of Resident R76's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/16/25. During an interview on 4/17/25, at 11:07 a.m. the Nursing Home Administrator confirmed that there was no evidence that a written notification of the facility bed hold policy was provided to the resident upon transfer to the hospital for two of two residents (Resident R47 and R76). 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.
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Page 12 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations and staff interviews, it was determined that the facility failed to provide language assistance services to maintain activities of daily living (ADLs) for communication for one of two residents (Resident R177).
Residents Affected - Few
Findings include: The facility Language assistance services policy reviewed 12/9/24, indicated that the facility will take responsible steps to ensure that individuals with limited English proficiency have access to language assistance services and meaningful communication involving their medical treatment. Review of Resident R177's admission record indicated she was admitted on [DATE]. Review of Resident R177's initial nurse assessment dated [DATE], indicated she had diagnoses that included hypotension (low blood pressure), wound of the left heel and cellulitis (bacterial infection of the skin causing redness, aches, and swelling) of both lower extremities. The assessment identified Resident R177 primary language as French. Review of Resident R177's care plan dated 3/28/25, indicated a language barrier. Review of Resident R177's clinical nurse progress note dated 4/8/25, indicated she only speaks French. During observations on 4/14/25, at 10:17 a.m. Resident R177 was observed in her room and only speaking French. During an interview on 4/15/25, at 9:54 a.m. Licensed Practical Nurse (LPN) Employee E6 stated: Nurse Aide (Na) Employee E7 is assigned to Resident R177. She has an application on her phone to communicate and she should know how to use it. We were told to get the app on our phone and that is how we communicate. During an interview on 4/15/25, at 9:56 a.m. Nurse Aide (NA) Employee E7 stated: I do not have an app on my phone. Resident R177 usually points to what she wants. This is my first time having her. She does not have a communication board. During an observations and interview on 4/15/25, at 10:00 a.m. an interview was attempted with Resident R177. Nurse aide (NA) Employee E8 present trying to use electronic phone application. Nurse aide (NA) Employee E8 stated: I have a translator app. All attempts to communicate with Resident R177 did not succeed. During an interview on 4/15/25, at 2:39 p.m. information disseminated to the Nursing Home Administrator (NHA) that the facility failed that the facility failed to provide language assistance services to maintain activities of daily living (ADLs) for communication for Resident R177 as required. 28 Pa. Code: 211.12(d)(5) Nursing services.
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Page 13 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, it was it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for three of four residents (Resident R16, R23, R52 and R128).
Residents Affected - Some
Findings include: Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/7/25, indicated diagnoses of right below the knee amputation, diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) , and peripheral vascular disease (a slow and progressive disease that impacts the blood vessels in the body outside the heart.) Review of Resident R16's active physician order dated 3/17/25, indicated to cleanse Resident R16's diabetic left plantar foot ulcer with normal saline solution (wound cleanser), pat dry, apply Mupirocin ointment (topical antibiotic for bacterial skin infections), and cover with a bordered dressing daily. During an observation on 4/14/25, at 2:05 p.m. Resident R16's left plantar foot wound dressing was dated 4/12/15. During an interview on 4/14/25, at 2:16 p.m. Licensed Practical Nurse, Employee E6 confirmed Resident R16's wound dressing was ordered daily and was dated 4/12/25. During an interview on 4/14/25, at 3:14 p.m. the Director of Nursing confirmed the facility failed to change Resident R16's wound dressing as ordered. Review of the clinical record revealed that Resident R23 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R23's MDS dated [DATE], indicated diagnoses of high blood pressure, peripheral vascular disease, and diabetes. Review of Resident R23's physician order dated 4/12/25, indicated to cleanse the vascular wound on the left shin with normal saline, pat dry, apply collagen (used to stimulate new tissue growth), calcium alginate highly absorbent dressings ideal for wounds with moderate to heavy exudate) to wound bed, cover with gauze island dressing daily and as needed. May cover with abdominal pad (pas that absorb fluid and create a moisture barrier for wounds) and wrap with kerlix (gauze bandage roll) if island dressing will not stick, every day shift for peripheral vascular disease. Review of Resident R23's April 2025 Treatment Administration Record (TAR) revealed Resident R23's left shin wound was changed as ordered on 4/13/25, 4/14/25, and 4/15/25. During an observation on 4/15/25, at 11:40 a.m. Resident R23 left lower leg wound dressing was dated 4/12/25. Resident R23 indicated staff were asked to change the dressing and no one has.
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Page 14 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0684
Level of Harm - Minimal harm or potential for actual harm
During an interview on 4/15/25, at 11:41 a.m. LPN, Employee E6 confirmed Resident R23's left lower leg wound dressing was not changed as ordered and dated 4/12/25. During an interview on 4/15/25, at 11:47 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to change Resident R23's wound dressing as ordered.
Residents Affected - Some During an interview on 4/16/25, at 11:11 a.m. Registered Nurse, Employee E10 stated if a resident's wound treatment was not completed, the next shift would be notified. RN, Employee E10 stated the order would not be signed off in the clinical record until it was completed. During an interview on 4/17/25, at 9:41 a.m. the DON confirmed the facility failed to provide necessary treatment as ordered for two of two residents (Resident R16 and R23.) Review of Resident R52's admission record indicated he was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 2/4/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and stage 4 chronic kidney disease (severe kidney function loss and high risk of complications and kidney failure). Review of Resident R52's physician order dated 2/2/25, indicated to administer 200 mg Cefpodoxime (antibiotic that treats bacterial infections), one tablet, by mouth twice daily related to stage 4 chronic kidney disease for 10 days. The order was created and confirmed by Registered Nurse, Employee E10. A further reviewed failed to indicate a physician signed off on the order. Review of Resident R52's February 2025 Treatment Administration Record revealed the resident received Cefpodoxime from 2/2/25, through 2/13/25. Review of Resident R52's clinical record revealed CRNP, Employee E20 evaluated Resident R52 on 2/12/25, for acute gastrointestinal pain. The resident had localized right and central region pain worse with palpitation that began that morning. The resident did not eat breakfast, had acute diarrhea, and was bloated. CRNP, Employee E52 indicated the resident's antibiotics may be contributing to the abdominal pain and the resident will remain on the antibiotics until 2/14/25. An abdominal x-ray and probiotics were ordered. Review of Resident R52's physician order dated 2/12/25, indicated to obtain an abdominal x-ray for left lower quadrant and central gastrointestinal pain, bloating, and diarrhea. Review of Resident R52's physician order dated 2/12/25, indicated to administer one capsule of 250 mg saccharomyces boulardii (probiotic yeast that can help support the digestive system), for probiotic for 14 days. Review of Resident R52's clinical record revealed CRNP, Employee E20 evaluated Resident R52 on 2/13/25, for acute gastrointestinal pain. It was documented the antibiotics may be a possible contribution and the resident will remain on the antibiotics until 2/14/25. The resident was receptive to trial IV fluids and Mylanta. Supportive care, possible viral cause. Review of Resident R52's progress note dated 2/13/25, indicated the resident called 911 5-6 times
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Page 15 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0684
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
this evening requesting transport to the hospital for complaint of abdominal pain. The x-ray results from 2/12/25 we normal. There was no evidence a physician was notified. Review of Resident R52's progress note dated 2/14/25, at 1:17 a.m. revealed the 911 operator called stating Resident R52 called them to go to the emergency room. RN Supervisor, Employee E24 went to see the resident and Resident R52 complained of severe back and kidney pain with severe diarrhea. Crying to go to hospital. There was no evidence a physician was notified. Review of Resident R52's progress note dated 2/14/25, at 2:38 a.m. revealed the resident was transferred to the hospital. Review of Resident R52's progress note dated 2/14/25, at 3:00 a.m. indicated the emergency room nurse called concerned about the resident receiving Cefpodoxime. It was confirmed the resident received Cefpodoxime from 2/2/25, until 2/13/25. Review of Resident R52's progress note dated 2/14/25, at 8:31 a.m. revealed the resident was admitted to the hospital with diagnoses of pyelonephritis (kidney infection). During an interview on 4/18/25, at 8:59 a.m. the NHA confirmed the facility failed to ensure Resident R52's Cefpodoxime was signed off by a physician prior to administering, and timely provide care and necessary treatment and services for Resident R52 during a change in condition. During an interview on 4/18/25, at approximately 2:10 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to make certain that residents were provided appropriate treatment and care for three of four residents (Resident R16, R23, and R52). Review of the clinical record indicated that Resident R128 was admitted on [DATE]. Review of Resident R128 MDS indicated a diagnosis of depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world), hypokalemia ( potassium blood level low), and seizure disorder (a brain condition that causes recurring seizures). Review of Resident R128 clinical record progress notes indicated the following changes in condition: 2/17/25 Dietary: Note Text : F/u for chewing difficulties. NSG reporting she is still having difficulties with minced texture, suggesting change to purees for improved tolerance/intake. Discussed plan with resident. Will also increase mighty shakes to twice a day (BID) due to ongoing poor intake. Plan: regular diet/puree texture, mighty shakes BID. Will continue to monitor intake/wt trends. 2/17/25 Nursing Regular diet texture. Loss of liquids or solids from mouth when eating or drinking. Holding food in mouth / cheeks or residual food in mouth after meals. Mood appears depressed, sad, tired/has little energy, sluggish, speaking slowly. Abdomen soft with bowel sounds active/normal for resident 2/17/25 Nursing Mechanically altered diet. Holding food in mouth / cheeks or residual food in mouth after meals. 2/18/25 Nursing Regular diet texture. Loss of liquids or solids from mouth when eating or drinking.
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Page 16 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0684
Level of Harm - Minimal harm or potential for actual harm
Holding food in mouth / cheeks or residual food in mouth after meals. Mood appears poor appetite, speaking slowly. 2/18/25 Nursing Resident is not swallowing medications, she is letting medications run out of her mouth, repeated queuing for resident to swallow.
Residents Affected - Some 2/19/25 Nursing Resident pocketed medications, continues not swallow, let medications run out of her mouth. 2/19/25 Nursing Appears lethargic.Oriented to person. Skin warm, dry, normal for age and race, wounds with the following treatment: Preventative skin measures in place. Regular diet texture. Loss of liquids or solids from mouth when eating or drinking. Holding food in mouth/cheeks or residual food in mouth after meals. Mood appears tired/has little energy, poor appetite, speaking slowly. 2/20/25 Nursing Nurse called RN to assess resident for change in condition. Resident was lethargic and would not open her eyes. Vitals BP 59/40 Pulse 46 Resp 14 02 73% temp 97.1. Took BP on other arm 120/70. Applied o2 5 liters, resident 02 went up to 78%. Applied non rebreather mask with 10 liters 02. 02 Sat went up to 85%. Resident became more alert and opened her eyes and began moaning. Called provider and EMS. PCMA approved resident to be sent to hospital. When EMS arrived, was unable to get BP from arms and got pressure from left leg BP 190/100 and pulse 46. Resident started having tremors. Resident was transferred to UPMC Mercy per family request. Review of clinical record Blood Pressure Summary indicated resident R128 blood pressure was out of range from 2/17/25 to 2/20/25 eight out of nine times with the following: 2/17/2025 21:26 147/97 mmHg (Lying l/arm) Diastolic High of 89 exceeded Systolic High of 139 exceeded 2/18/2025 21:15 165/90 mmHg (Sitting l/arm) Diastolic High of 89 exceeded Systolic High of 139 exceeded 2/19/2025 00:07 158/88 mmHg (Lying r/arm) Systolic High of 139 exceeded 2/19/2025 11:34 140/84 mmHg (Lying r/arm) Systolic High of 139 exceeded 02/19/2025 11:47 140/84 mmHg (Lying r/arm) Systolic High of 139 exceeded 02/19/2025 16:38 138/96 mmHg (Sitting l/arm) Diastolic High of 89 exceeded 02/19/2025 21:23 119/100 mmHg (Lying l/arm) Diastolic High of 89 exceeded 02/20/2025 04:17 49/40 mm/Hg (Lying l/arm) Diastolic Low of 60 exceeded Systolic Low of 90 exceeded Review of hospital information indicated the following: Hospital Course - final report Nutrition Status: Severe Malnutrition in the context of Social or Environmental Circumstances; Severe
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Page 17 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0684
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
protein-calorie malnutrition; >7.5% weight loss in 3 months (31% x 2 months)' Severe body fat loss; Severe muscle mass loss.Weight comorbidity: underweight. [AGE] year old female was found to have AKI (acute kidney injury happens when the kidneys suddenly can't filter waste products from the blood), hypernatremia, and admitted for further management. AM cortisol and B12 slightly elevated. Urine culture grew ESBL Klebsiella. Given IV fluids, with subsequent improvements in Creatine, sodium and calcium levels. Her mentation improved back to baseline. Renal failure, electrolyte derangement were treated however d/t ongoing encephalopathy and FTT Resident R128 did not tolerate adequate to sustain life. During an interview on 4/ 17/25, DON confirmed that the facility is capable of doing IV's or pushing fluids and had not identified hydration as a concern, that Resident R128 was having a change of condition prior to discharge to hospital, that the facility did not initiate labs to determine if there were any additional concerns for Creatine, sodium or calcium levels, and the facility failed to identify concerns for a potential AKI injury and that the facility failed to provide a quality of care for Resident R128. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(a)(c)(d)(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
395666
Page 18 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0693
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Residents R13 and Resident R35).
Findings include: Review of facility policy Care and Treatment of Feeding Tubes dated 12/9/24, indicated the facility will utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes will be utilized according to physician orders. The resident's care plan will address the use of feeding tube, including strategies to prevent complications. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location; tube placement will be verified before beginning a feeding and before administering medications. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, indicated diagnoses of high blood pressure, heart failure (heart doesn't pump the way it should) and chronic obstructive pulmonary disease (COPD- difficulty in breathing). Section K- Swallowing/Nutritional Status indicated the resident had a feeding tube while a resident. Review of Resident R13's physician orders dated 2/11/25, indicate nothing by mouth diet (NPO). Review of Resident R13's physician orders dated 2/12/25, indicate Enteral Feed every shift for nutrition Glucerna: 1.2 Calorie administer continuous via Pump at 70 milliliter (ML) per hour flush with 25ml per hour for 20 Hours per day or until total nutrient delivered (1400ml), Downtime: 4:00 p.m. back up at 8:00 p.m. Review of Resident R13's medication administration record (MAR) for April 2025, failed to reveal enteral feeding tube orders prior to 4/15/25, which addressed appropriate treatment and services related to checking for tube feeding residuals, and elevate the head of bed during enteral feeding administration. Review of Resident R13's MAR for March 2025, failed to reveal enteral feeding tube orders prior to 4/15/25, which addressed appropriate treatment and services related to checking for tube feeding residuals, and elevate the head of bed during enteral feeding administration. During an interview on 4/18/25, at 9:18 a.m., the Director of Nursing (DON) confirmed that prior to physician orders for enteral feeding treatment and services entered on 4/15/25, Resident R13 did not have physician orders to check residuals, or to elevate the head of bed during enteral feeding administration. Review of clinical record revealed Resident R35 was admitted to facility initially 2/11/18, with
395666
Page 19 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0693
current admission date of 1/12/21.
Level of Harm - Minimal harm or potential for actual harm
Review of Resident 35's MDS dated [DATE], indicated diagnoses major depressive disorder (mental disorder characterized by a persistent low mood, loss of interest or pleasure in activities, and a range of emotional and physical problems), adult failure to thrive (condition characterized by a decline in physical and mental health, often seen in older adults), and dysphagia (difficulty swallowing foods or fluids). Section K- Swallowing/Nutritional Status indicated the resident had a feeding tube while a resident.
Residents Affected - Few
Review of Resident R35's physician order dated 10/31/23, indicated nothing by mouth diet, NPO texture. Review of Resident R35's MAR for April 2025, indicated an enteral feed order every shift for feeding administer Osmolite 1.5 (a type of feeding formula that will supply a person with nutrients and minerals) via pump at 95 ml (milliliters) per hour for 16 hours daily for total 1620 ml, start at 6:00 p.m. every day, initiated 4/12/25, and discontinued 4/15/25. During an observation made on 4/14/25, at 12:45 p.m., enteral feeding tube formula of Osmolite 1.2 was hanging at Resident R35's bedside and failed to have a date written on the container when opened. During an interview conducted on 4/14/25, at 12:50 p.m., Registered Nurse (RN) Employee E27 confirmed that Resident R35's enteral tube feeding formula found hanging was incorrect per physician order and was undated when opened. Review of Resident R35's physician orders dated 4/15/25, indicated: - enteral feed order as needed verify placement. Flush enteral tube with at least 15 ml of water. Then flush with 15 ml of water after administration of each medication. - enteral feed order every shift check residual, signs/symptoms intolerance every shift. Hold and notify of signs/symptoms intolerance. - enteral feed order every shift for feeding administer Osmolite 1.5 (Jevity 1.5 if Osmolite not available) via pump at 95 ml per hour for 16 hours daily for total 1520 ml. Start 6:00 p.m., down at 10:00 a.m. - enteral feed order every shift verify placement. Flush enteral tube with at least 15 ml of water. Then flush with 15 ml of water after administration of each medication. - enteral feed: elevate head of bed 30-45 degrees during feeding and for 30-45 minutes after every shift. During a follow-up observation conducted on 4/16/25, at 11:58 a.m., Resident R35's enteral feeding pole and floor area underneath were found dirty with what appeared to be spilled or leaked enteral formula which was dried covering the surface of the pole, 4 legs above the casters, and floor below where pole was located. During an interview on 4/16/25, at 12;21 p.m., RN Employee E27 confirmed the above observation of
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Page 20 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0693
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Resident R35's dirty enteral pole and floor below with what appeared to be spilled or leaked enteral formula. Further review of Resident R35's MAR for April 2025, failed to reveal enteral feeding tube orders prior to 4/15/25, which addressed appropriate treatment and services related to verifying tube feeding placement, checking for tube feeding residuals, and elevate the head of bed during enteral feeding administration. Review of Resident R35's MAR for March 2025, failed to reveal enteral feeding tube orders prior to 4/15/25, which addressed appropriate treatment and services related to verifying tube feeding placement, checking for tube feeding residuals, and elevate the head of bed during enteral feeding administration. During an interview on 4/18/25, at 9:18 a.m., the DON confirmed that prior to physician orders for enteral feeding treatment and services entered on 4/15/25, Resident R35 did not have physician orders to verify tube feeding placement, to check residuals, or to elevate the head of bed during enteral feeding administration. During an interview on 4/18/25, at 2:30 p.m., the Nursing Home Administrator (NHA) and DON confirmed that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Residents R13 and Resident R35). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.
395666
Page 21 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide effective pain management for one of four residents reviewed (Resident R16).
Residents Affected - Few
Findings include: Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE], with diagnoses of right below the knee amputation, diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and peripheral vascular disease (a slow and progressive disease that impacts the blood vessels in the body outside the heart.) Review of Resident R16's care plan dated 1/3/25, revealed the resident was care planned for pain. Interventions included to administer medication per physician orders. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/7/25, indicated diagnoses were current. Review of Resident R16's physician order dated 4/11/25, indicated to administer 15 milligram of MS Contin (also known as morphine, a strong opioid pain medication for moderate to severe pain), one tablet by mouth, three times a day. During an interview on 4/14/25, at 2:20 p.m. it was revealed Resident R16 was experiencing phantom pain. Resident R16 stated the oxycodone was lowered, and morphine was ordered. Resident R16 had not received the morphine for pain. Resident R16 stated I am not sure if it is in stock. Review of Resident R16's clinical record on 4/15/25, at 9:02 a.m. revealed Resident R16 failed to receive MS Contin as ordered at the following scheduled times. -4/13/25, at 2:00 p.m. -4/13/25, at 10:00 p.m. -4/14/25, at 6:00 a.m. -4/14/25, at 2:00 p.m. It was indicated there was no medication in stock at this time. Interview with the Director of Nursing on 4/17/25, at 2:19 p.m. confirmed the facility failed to provide effective pain management for one of four residents reviewed (Resident R16). 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
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Page 22 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records and staff interviews, it was determined that the facility failed to maintain a complete record of a dialysis contract for one of two sampled residents (Resident R22).
Residents Affected - Few
Findings include: Review of Resident R22's admission record indicated she was admitted [DATE]. Review of Resident R22's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 2/12/25, indicated she had diagnoses that included end stage renal disease (gradual loss of kidney function), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and vascular dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning). Review of Resident R22's care plan dated 2/12/25, indicated she had dialysis three times a week Review of Resident R22's physician orders dated 2/28/25, indicated that she was ordered dialysis Monday, Wednesday and Friday. The location of the dialysis provider was on file. Review of Resident R22's nurse progress notes dated 4/14/25, indicated that she left the facility via wheelchair van to dialysis. Review of Resident R22's clinical records did not include a contract with the dialysis provider. Review of facility documents did not include a contract for the dialysis provider. During an interview on 4/15/25, at 9:24 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to maintain a complete record of a dialysis contract for Resident R22 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies.
395666
Page 23 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R278).
Residents Affected - Few
Findings include: Review of facility policy Comprehensive Care Plans last reviewed 12/9/24, revealed it is the policy of the facility to develop and implement a comprehensive care plan for each resident, consistent with resident rights, that includes measureable objectives and timeframes to meet a resident's medica;, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and [NAME] professional standards of quality. Review of the clinical record indicated Resident R278 was admitted to the facility on [DATE]. Review of Resident R278's physician order dated 4/1/25, indicated to consult psychiatry. Review of Resident R278's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/7/25, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), acquired absence of right leg below knee, and insomnia (difficulty staying or falling asleep). Review of Resident R278's care plan indicated that resident had PTSD but failed to identify what the triggers were and how to avoid them. During an interview on 4/14/25, at 9:55 a.m. Resident R278 stated I have a history of PTSD from losing my leg. Resident R278 stated the facility failed to identify my triggers, and I am afraid of going to hospitals and doctors. It was indicated the facility does not have a social worker. Did they stick me in a zoo? Resident R278 stated I am more traumatized while being here. A review of Resident R278's clinical record on 4/17/25, at 10:57 a.m. revealed the facility failed to complete an assessment and identify Resident R278's PTSD triggers. There was no evidence Resident R278 was evaluated by psychiatry or had a psychology visit. Review of Resident R278's care plan failed to include a care plan for PTSD. During an interview on 4/17/25, at 2:22 p.m. the Director of Nursing confirmed the facility failed to identify Resident R278's PTSD triggers. The DON indicated normally the psychology provider comes in every Tuesday. The DON stated Resident R278 should have been evaluated on 4/6/25. It was indicated the psychology provider that rounds the facility came in on Tuesday and stated I am going to roll. The DON stated she's afraid of you guys. During an interview on 4/17/25, at 3:17 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to identify PTSD triggers for Resident R278 to eliminate or mitigate any triggers that may cause re-traumatization for one of two residents (Resident R278). 28 Pa. Code: 201.14(a) Responsibility of licensee.
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Page 24 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0699
28 Pa. Code: 201.18(b)(1) Management.
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
395666
Page 25 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0710
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and interviews with staff, it was determined that the facility failed to ensure a medication was signed off by a physician prior to administering, and timely provide care and necessary treatment and services for one of two residents (Resident R52).
Residents Affected - Few
Findings include: Review of the facility policy Administering Medications last reviewed 12/9/24, revealed medications are administered vin a safe and timely manner, and as prescribe. If dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associate with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Review of the facility policy Provision of Quality Care last reviewed 12/9/24, revealed the facility will ensure residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive care plans, and the resident's choices. Review of Cefpodoxime (antibiotic that treats bacterial infections) manufacturer guidelines dated 10/16/13, indicated for patients with severe renal impairment the dosing intervals should be increased to every 24 hours. Adverse interactions include gastrointestinal disturbances such as diarrhea, nausea, and vomiting. Review of Resident R52's admission record indicated he was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 2/4/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and stage 4 chronic kidney disease (severe kidney function loss and high risk of complications and kidney failure). Review of Resident R52's physician order dated 2/2/25, indicated to administer 200 mg cefpodoxime, one tablet, by mouth twice daily related to stage 4 chronic kidney disease for 10 days. The order was created and confirmed by Registered Nurse, Employee E10. A further reviewed failed to indicate a physician reviewed and confirmed the order. Review of Resident R52's February 2025 Treatment Administration Record revealed the resident received cefpodoxime from 2/2/25, through 2/13/25. Review of Resident R52's clinical record revealed CRNP, Employee E20 evaluated Resident R52 on 2/12/25, for acute gastrointestinal pain. The resident had localized right and central region pain worse with palpitation that began that morning. The resident did not eat breakfast, had acute diarrhea, and was bloated. CRNP, Employee E52 indicated the resident's antibiotics may be contributing to the abdominal pain and the resident will remain on the antibiotics until 2/14/25. Review of Resident R52's clinical record revealed CRNP, Employee E20 evaluated Resident R52 on 2/13/25, for acute gastrointestinal pain. It was documented the antibiotics may be a possible
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Page 26 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0710
contribution and the resident will remain on the antibiotics until 2/14/25.
Level of Harm - Minimal harm or potential for actual harm
Review of Resident R52's progress note dated 2/13/25, at 9:03 p.m. indicated the resident called 911 5-6 times this evening requesting transport to the hospital for complaint of abdominal pain.
Residents Affected - Few
Review of Resident R52's progress note dated 2/14/25, at 1:17 a.m. revealed the 911 operator called stating Resident R52 called them to go to the emergency room. RN Supervisor, Employee E24 went to see the resident and Resident R52 complained of severe back and kidney pain with severe diarrhea. Crying to go to hospital. Review of Resident R52's progress note dated 2/14/25, at 2:38 a.m. revealed the resident was transferred to the hospital. Review of Resident R52's progress note dated 2/14/25, at 3:00 a.m. indicated the emergency room nurse called concerned about the resident receiving cefpodoxime. It was confirmed the resident received cefpodoxime from 2/2/25, until 2/13/25. Review of Resident R52's progress note dated 2/14/25, at 8:31 a.m. revealed the resident was admitted to the hospital with diagnoses of pyelonephritis (kidney infection). During an interview on 4/16/25, at 11:22 a.m. CRNP, Employee E20 was asked what is the process for sending a resident out to the hospital, and stated the provider would be notified and orders are obtained to treat or send out to the hospital. When asked who confirms physician orders, CRNP, Employee E20 stated that's a question for the DON. During an interview on 4/16/25, at 11:34 a.m. the Director of Nursing stated each morning an order recap report is reviewed and the DON confirms the orders if nothing stands out. I'm not a pharmacist the DON stated. The DON stated all orders must be signed by a provider. The DON confirmed Resident R52's cefpodoxime was not signed off by a physician. During an interview on 4/18/25, at 8:59 a.m. the NHA confirmed the facility failed to ensure Resident R52's cefpodoxime was signed off by a physician prior to administering, and timely provide care and necessary treatment and services for one of two residents (Resident R52). 28 Pa. Code:211.12(d)(5) Nursing services.
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0726
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Based on review of facility policy, nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for three out of five sampled nursing personnel records (Registered Nurse (RN) Employee E16 , Licensed Practical Nurse (LPN) Employee E25, and Registered Nurse (RN) Employee E26).
Findings include: The facility Training requirements policy last reviewed on 12/9/24, indicated that the facility will develop, implement and maintain an effective training program for all new and existing staff. Training contents includes, at the minimum communication, resident rights, elements of the facility's QAPI (quality assurance and performance improvement), infection control, ethics, behavioral health, dementia management, abuse/ neglect, and safety and emergency procedures. Review of Registered Nurse (RN) Employee E16 personnel record indicated she was hired on 11/3/10. Review of Licensed Practical Nurse (LPN) Employee E25 personnel record indicated she was hired on 12/1/03. Review of Registered Nurse (RN) Employee E26 personnel record indicated she was hired on 9/4/14. Review of personnel records for Registered Nurse (RN) Employee E16 , Licensed Practical Nurse (LPN) Employee E25, and Registered Nurse (RN) Employee E26 did not include annual in-services for the following subjects: infection prevention and control, fire prevention and safety, disaster preparedness, resident abuse, resident confidential information, Quality assurance, resident psychosocial needs, restorative nursing techniques, resident rights, cultural competency, and communication. During an interview on 4/18/25, at 11:28 a.m . the Human Resources Employee E5 confirmed that the facility failed to ensure that Registered Nurse (RN) Employee E16 , Licensed Practical Nurse (LPN) Employee E25, and Registered Nurse (RN) Employee E26 received annual in-service education as required. 28 Pa. Code: 201.14(1) Responsibility of licensee. 28 Pa. Code: 201.18(a)(3) Management.
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0740
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to provide behavioral health interventions for a resident to maintain the highest practicable mental well-being for one of four residents reviewed for behavioral concerns (Resident 16).
Findings include: Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's active physician order dated 1/2/25, indicated to consult psychiatry. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/7/25, indicated diagnoses of right below the knee amputation, diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) , and peripheral vascular disease (a slow and progressive disease that impacts the blood vessels in the body outside the heart.) Review of Resident R16's care plan dated 1/14/25, revealed the resident uses an antidepressant medication due to major depressive disorder. Interventions included to monitor signs and symptoms of depression and refer to psychology services as appropriate. During an interview on 4/14/25, at 2:25 p.m. Resident R16 was observed with a right leg amputation and expressed God hates me. Resident R16 explained the amputation occurred around Thanksgiving. No one has seen me for psychology services. Review of Resident R16's clinical record on 4/17/25, at 9:17 a.m. failed to provide evidence Resident R16 was evaluated by psychiatry as ordered. During an interview on 4/17/25, at 2:22 p.m. the Director of Nursing indicated normally the psychology provider comes in every Tuesday. It was indicated the psychology provider that rounds the facility came in on Tuesday and stated I am going to roll. The DON stated the psychology provider is afraid of you guys. During an interview on 4/17/25, at 3:17 p.m. the Nursing Home Administrator and DON confirmed the facility failed to provide behavioral health interventions for a resident to maintain the highest practicable mental well-being for one of four residents reviewed for behavioral concerns (Resident 16). 28 Pa. Code 211.12(d)(1)(5) Nursing services
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0745
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview it was determined that the facility failed to provide medically related social services to one of two residents reviewed (Resident R128).
Residents Affected - Few
Findings include: Review of the clinical record indicated that Resident R128 was admitted on [DATE]. Review of Resident R128 MDS indicated a diagnosis of depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world), hypokalemia ( potassium blood level low), and seizure disorder (a brain condition that causes recurring seizures). Review of Resident R128 physician orders dated 1/18/25, indicated to administer Selegeline Transdermal Patch 24 Hour 12 MG/24 HR, one patch transdermally (on top of skin) at bedtime for depression related to major depressive disorder Review of Resident R128 MAR (medication administration record) and review of clinical progress notes indicated missed doses of selegeline for multiple days: 1/18/25 thru 1/26/25. Review of Resident R128 clinical record indicated selegeline was discontinued - with no additional medication for depression prescribed. Additional review of Resident R128 clinical record failed to indicate any referrals for psych services for depression diagnosis. During an interview on 4/17/25, 1:50 p.m. DON (Director of Nursing) confirmed that the medication was discontinued and the facility did not provide referrals for psych services related to the depression diagnosis. 28 Pa. Code 211.16 (a) Social services.
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents (Residents R51 and Resident R128).
Findings include: Review of the facility policy, Pharmacy Services last reviewed 12/9/24, indicated to ensure pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The facility will maintain a limited supply of medications for emergency or after-hours situations in accordance with facility policy and applicable laws. Review of the facility policy Unavailable Medications last reviewed 12/9/24, indicates the facility maintains a contract with a pharmacy provider to supply the facility with routine, prn, and emergency medications. The facility shall follow established procedures for ensuring residents have a sufficient supply of medication. Review of Residents R51's admission record indicated admission to the facility on 8/28/23. Review of Residents R51's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/10/25, indicated the diagnoses of high blood pressure, anxiety and depression. During an observation completed on 4/16/25, at 8:51 a.m. Registered Nurse (RN)Employee E27 was preparing medications for Resident R51. RN Employee E27 was not able to find Resident R51's Zoloft (used to treat depression and anxiety). Upon asking RN Employee E27 the process for unavailable medications she replied I will have to get it pulled from the pyxis (drug distribution system), I will have to get someone who has access to the machine. RN Employee E27 stated the machine was on the first floor. RN Employee E27 asked RN Employee E10 to assist with obtaining the medication. Upon pulling the medication from the pysis machine RN Employee E10 opened the drawer to dispense and discovered only one pill was available at 25 milligram (mg). The machine screen visualized indicated that four 25mg tablets should have been in the drawer. RN Employee E10 stated the screen says four but only one is available in here it looked like we had enough I don ' t know why it's off. RN Employee indicated that pharmacy would have to be called to have it delivered. During an interview completed on 4/16/25, at 9:37 a.m. with the Nursing Home Administrator (NHA) and Director of Nursing (DON) upon asking the procedure for unavailable medications not available in the pyxis machine the DON indicated the pharmacy comes in around 11:00 p.m. our cut off time is 5:00 p.m. Upon inquiring the process for unavailable medications and the utilization of a local backup pharmacy the DON replied we don't have a backup pharmacy if you do a stat they will have a run around 1:00 p.m. or 2:00 p.m. then again at midnight we use Phar -America we need to call at midmorning for the run and stated I'm going to be making some calls now and get the pharmacy here. During an interview completed on 4/16/25 at 10:54 a.m. upon asking the pharmacy director (PD) Employee E28 about a local back up pharmacy she replied we can use any local pharmacy and get it filled. Upon asking PD Employee E28 about the restocking/monitoring of the pyxis machine as well as
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
medication reconciliation concerning off counts/discrepancies replied we pull a report on Mondays and Wednesdays for the restock. The facility can also call and let us know when the medication needs to be refilled and we can send it out on the run, the nurses can then put it in the pyxis Upon further inquiry concerning medication discrepancy concerning the Zoloft stated any time the count is off they should notify the pharmacy and do a discrepancy, we have not received any phone calls. Further inquiry into the Zoloft count PD Employee E28 replied I pulled up the report and it indicated that seven Zoloft tablets were available upon inspection of the Zoloft available in the pyxis the machine at that time showed 0 and stated I don ' t think I can pull anything off this machine to indicate who the user was, they should put in how much they are taking and it is automatically adjusted. Review of the pharmacy provided pyxis inventory reports indicated the following medications at zero (0). Lantus Solostar Insulin Pen (long acting insulin to improve blood sugar control) Levothyroxine 0.088 mg (used to treat hypothyroidism-thyroid gland does not produce enough thyroid hormone) Humalog Insulin Pen (fast acting insulin used to lower blood sugars) Advair Diskus inhaler (prevents asthma attacks and Chronic Obstructive Pulmonary Disease (COPD-difficulty in breathing) flare ups. Ventolin inhaler (helps with trouble breathing) Bumetanide 0.5 mg tablets (diuretic- reduces fluid retention) Bumetanide 1 mg tablets (diuretic- reduces fluid retention) The PD Employee E28 stated someone is coming down now, if the facility made us aware of the empty medications it would have been sent with the run, there is no reason for these to be at zero. During an interview completed on 4/17/25, at 10:12 a.m. the Pharmacy Technician Employee E29 was at the pyxis machine restocking the medications. Upon asking how often the machine is restocked stated it depends on the list and time restraints, and review of the list about once a month, I get the list every Wednesday morning so I lock once a week, I'm only here two days a week , someone else can be looking at it, but I'm not aware of that. I just put the medications in the machine, the facility has not called to request any medications, I don ' t know if that ever happened. Upon asking about medication discrepancies Pharmacy Technician Employee E29 stated any discrepancies in the drawers should be taken care of by the facility and pharmacy director, if it is a controlled substance it should be immediately. During an interview on 4/17/25, at 3:19 p.m. the Nursing Home Administration and Director of Nursing confirmed that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents. (Resident R51). Review of the clinical record indicated that Resident R128 was admitted on [DATE]. Review of Resident R128 MDS dated [DATE], indicated a diagnosis of depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world), hypokalemia ( potassium blood level low), and seizure disorder (a brain condition that causes recurring
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2170 Rhine Street Pittsburgh, PA 15212
F 0755
seizures).
Level of Harm - Minimal harm or potential for actual harm
Review of Resident R128 physician orders indicted the following: Dorzolamide HCl-Timolol Mal Ophthalmic Solution
Residents Affected - Some 2-0.5 % (Dorzolamide HCl-Timolol Maleate) Instill 1 drop in both eyes two times a day for Glaucoma Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime for glaucoma related to UNSPECIFIED GLAUCOMA (H40.9 Selegeline HCl Oral Capsule 5 MG (Selegeline HCl) Give 1 capsule by mouth two times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS (G20. Selegeline Transdermal Patch 24 Hour 12 MG/24 HR (Selegeline) Apply 1 patch transdermally at bedtime for Depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED (F33.9) Zonisamide Oral Capsule 25 MG (Zonisamide) Give 25 mg by mouth in the morning for Seizures Pharmacy Review of clinical record progress notes indicated the following medications were not available and not given: 1/19/25 11:13: Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % Instill 1 drop in both eyes two times a day for Glaucoma
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2170 Rhine Street Pittsburgh, PA 15212
F 0755
Awaiting arrival from pharmacy
Level of Harm - Minimal harm or potential for actual harm
1/19/25 22:00: Selegeline Transdermal Patch 24 Hour 12 MG/24 HR
Residents Affected - Some Apply 1 patch transdermally at bedtime for Depression awaiting arrival from pharmacy 1/20/25 20:40 clonidine HCl Oral Tablet 0.1 MG Give 0.1 mg by mouth two times a day for Hypertension on order 1/20/25 20:41: Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % Instill 1 drop in both eyes two times a day for Glaucoma waiting for medication to be delivered Selegeline Transdermal Patch 24 Hour 12 MG/24 HR Apply 1 patch transdermally at bedtime for Depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED (F33.9) waiting for medication to be delivered 1/21/25 13:58: Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % Instill 1 drop in both eyes two times a day for Glaucoma on order from pharmacy 1/21/25 20:36: Selegeline Transdermal Patch 24 Hour 12 MG/24 HR Apply 1 patch transdermally at bedtime for Depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED (F33.9) not avail
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0755
Review of Resident R128 progress notes dated 1/22/25, signed by NP (Nurse Practioner) failed to include any mention of the missed medication.
Level of Harm - Minimal harm or potential for actual harm
1/22/25 21:35:
Residents Affected - Some
Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % Instill 1 drop in both eyes two times a day for Glaucoma on order, waiting for medication to be delivered 1/22/25 21:36: Selegeline Transdermal Patch 24 Hour 12 MG/24 HR Apply 1 patch transdermally at bedtime for Depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED (F33.9) on order 1/22/25 21:36: Selegeline Transdermal Patch 24 Hour 6 MG/24 HR Apply 12 mg transdermally at bedtime for Parkinson's related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS (G20.A1) STAT DELIVERY on order 1/24/25 20:27: Selegeline Transdermal Patch 24 Hour 12 MG/24 HR Apply 1 patch transdermally at bedtime for Depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED (F33.9) on order 1/24/25 20:49: Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % Instill 1 drop in both eyes two times a day for Glaucoma on order Review of clinical record progress notes dated 1/25/25, indicated Selegeline Transdermal Patch 24
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2170 Rhine Street Pittsburgh, PA 15212
F 0755
Hour 12 MG/24 HR, was discontinued.
Level of Harm - Minimal harm or potential for actual harm
Review of clinical record progress notes dated 1/26/25, indicated Resident is alert and oriented x2 with some confusion. Resident is on thin liquids and regular texture diet. Resident will take medications whole, but will sometimes request to have them crushed in pudding. Resident has a history of Parkinson's and does experience tremors from time to time.
Residents Affected - Some
1/28/25 20:30: Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % Instill 1 drop in both eyes two times a day for Glaucoma on order 1/29/25 21:59: Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % Instill 1 drop in both eyes two times a day for Glaucoma awaiting arrival from pharmacy 2/1/25 20:17: Selegeline HCl Oral Capsule 5 MG Give 1 capsule by mouth two times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS (G20.A1) reordered 2/4/25 20:51: Amantadine HCl Oral Capsule Give 100 mg by mouth two times a day for Blood Pressure related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) not on hand, waiting for medication to be delivered. During an interview on 4/17/25, at 2:00 p.m. DON confirmed the above missed doses of selegeline HCI oral capsule, Amantadine, selegeline, dorzolamide, were not in the facility and although ordered resident went without the medication as ordered and the facility failed to provide accurate pharmaceutical services. 28 Pa. Code 201.14 (a) Responsibility of licensee.
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2170 Rhine Street Pittsburgh, PA 15212
F 0755
28 Pa. Code 211.9 (a)(1)(k)(l)(1)(2)(3)(4) Pharmacy services
Level of Harm - Minimal harm or potential for actual harm
28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.
Residents Affected - Some
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0756
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regimen reviews (MRR) by pharmacy were acted upon timely for two out of two residents (Resident R2 and R69).
Findings include: Review of facility policy Medication Regimen Review last reviewed on 12/9/24, indicated the drug regimen is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The MMR, or drug regimen review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medication. The MMR includes: a. Review of the medical record in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities. b. Collaboration with other members of the interdisciplinary team, including the resident, their family and/or resident representative. The requirements associated with the MRR apply to all residents, whether short or long stay. The pharmacist shall communicate any irregularities to the facility in the following ways: a. Verbal communication to the attending physician, the facilities medical director and or the staff of any urgent needs. b. Written communication to the attending physician, the facilities medical director and the director of nursing. Written communications from the pharmacist shall become a permanent part of the resident's medical record. Review of Resident R2's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident 2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/25, indicated diagnoses of Alzheimer's disease (most common cause of dementia, characterized by a progressive decline in memory, thinking, and behavior), heart failure, and diabetes mellitus (endocrine disease characterized by sustained high blood glucose levels). Section N0415 - Medications high risk drug classes use and indication indicates resident is taking antipsychotic, antianxiety, and antidepressant medications. Review of Resident R2's physician order dated 2/17/25, indicated Escitalopram Oxalate (Lexapro-medication used to increase Serotonin in the brain that influences mood, sleep, digestion and more) oral tablet 10 milligram (MG) Give 1 tablet by mouth at bedtime related to major depressive disorder, recurrent, severe with psychotic symptoms.
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0756
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Review of Resident R2's physician order dated 2/17/25, indicated Quetiapine Fumarate (Seroquel medication used to balance dopamine and Serotonin levels in the brain, helping to calm psychotic thoughts and improve mood) oral tablet 100 MG Give 1 tablet by mouth three times a day for mood disorder related to major depressive disorder, recurrent, severe with psychotic symptoms. Review of Resident R2's physician order dated 4/11/25, indicated Lorazepam (Ativan - medication used for anxiety disorders) oral concentrate 2 milligram per milliliter (MG/ML) Give 0.25 ML by mouth every four hours as needed for anxiety related to Alzheimer's disease, schizoaffective disorder, anxiety disorder. During a review of Resident R2's medication administration record (MAR) on 4/18/25, the above orders were active. During a review of Resident 2's progress notes on 04/18/25, at 8:39 a.m. indicated: - Pharmacy Drug Regimen Review was completed on 10/15/24, Medical chart reviewed - recommendations made. - Pharmacy Drug Regimen Review was completed on 12/14/24, Medical chart reviewed - recommendations made. - Pharmacy Drug Regimen Review was completed on 1/16/25, Medical chart reviewed - recommendations made. - Pharmacy Drug Regimen Review was completed on 2/10/25, Medical chart reviewed - recommendations made. - Pharmacy Drug Regimen Review was completed on 3/11/25, Medical chart reviewed - recommendations made. A review of Resident R2's clinical record on 4/18/25, failed to include the above information containing the recommendations that were made by pharmacy drug regimen review. A review of Resident R69's clinical record on 4/15/25, failed to include the above information containing the recommendations that were made. Review of Resident R69's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R69's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety and depression. Section N0415 - Medications high risk drug classes use and indication indicates resident is taking antianxiety and antidepressant medications. Review of Resident R69's physician orders dated 3/4/25, indicated Escitalopram Oxalate (Lexapro-medication used to increase Serotonin in the brain that influences mood, sleep, digestion and more) oral tablet 20 milligram (MG) Give one tablet by mouth one time a day related to major depressive disorder. Review of Resident R69's physician orders dated 3/14/25, indicated Lorazepam (Ativan - used for
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anxiety disorders) give one tablet by mouth three times a day for anxiety
Level of Harm - Minimal harm or potential for actual harm
Review of Resident R69's physician order dated 3/29/25, indicated buspirone HCl Oral Tablet 10 MG (Buspar--an antianxiety medication that effects chemicals in the brain) Give one tablet by mouth two times a day for anxiety.
Residents Affected - Some During a review of Resident R69's medication administration record (MAR) on 4/15/25, the above orders were active. During a review of Resident R69's progress notes on 04/16/25, at 10:44 a.m. indicated: - Pharmacy Drug Regimen Review was completed on 2/10/25, Medical chart reviewed - recommendations made. - Pharmacy Drug Regimen Review was completed on 3/11/25, Medical chart reviewed - recommendations made. A review of Resident R69's clinical record on 4/15/25, failed to include the above information containing the recommendations that were made. During an interview completed on 4/17/25, at 11:33 a.m. the Director of Nursing (DON) confirmed Resident R69's recommendations for the physician response for the MRR's were not available in resident R69's clinical record. Upon asking what is the procedure in place for the MRR's, the DON stated the pharmacy faxes them over and I hand deliver to the physician, it varies, if I see them in the medication delivery box I grab them upon further asking the DON about monitoring the physician responses he replied I don't know a lot about it, there is not a process in place for the MRR's. During an interview on 4/18/25, at 2:30 p.m., the DON confirmed the facility failed to ensure that any irregularities submitted in the medication regimen reviews (MRR) by pharmacy were acted upon timely for two out of two residents (Resident R2 and R69). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing services.
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Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, and staff interview it was determined the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of three residents (Resident R2) reviewed.
Findings Include: Review of facility policy Use of Psychotropic Medications dated 12/9/24, indicated this policy is to ensure that residents only receive psychotropic mediations when other nonpharmacological interventions are clinically contraindicated. Additionally, these medication should only be used to treat the resident's medical symptoms and not used for disciple or staff convenience. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications are to be used only when a practioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Review of Resident R2's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident 2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/25, indicated diagnoses of Alzheimer's disease (most common cause of dementia, characterized by a progressive decline in memory, thinking, and behavior), heart failure, and diabetes mellitus (endocrine disease characterized by sustained high blood glucose levels). Section N0415 - Medications high risk drug classes use and indication indicates resident is taking antipsychotic, antianxiety, and antidepressant medications. Review of Resident R2's physician order dated 2/17/25, indicated Escitalopram Oxalate (Lexapro-medication used to increase Serotonin in the brain that influences mood, sleep, digestion and more) oral tablet 10 milligram (MG) Give 1 tablet by mouth at bedtime related to major depressive disorder, recurrent, severe with psychotic symptoms. Review of Resident R2's physician order dated 2/17/25, indicated Quetiapine Fumarate (Seroquel medication used to balance dopamine and Serotonin levels in the brain, helping to calm psychotic thoughts and improve mood) oral tablet 100 MG Give 1 tablet by mouth three times a day for mood disorder related to major depressive disorder, recurrent, severe with psychotic symptoms. Review of Resident R2's physician order dated 4/11/25, indicated Lorazepam (Ativan - medication used for anxiety disorders) oral concentrate 2 milligram per milliliter (MG/ML) Give 0.25 ML by mouth every four hours as needed for anxiety related to Alzheimer's disease, schizoaffective disorder, anxiety disorder. Review of Resident R2's medication administration record (MAR) for April 2025, indicated Lorazepam oral concentrate 2 MG/ML Give 0.25 ML by mouth every twelve hours as needed for anxiety with a start
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date of 6/7/24, end date (discontinue date) 4/11/25.
Level of Harm - Minimal harm or potential for actual harm
Review of Resident R2's clinical record from 6/7/24, through 4/10/25, failed to indicate a rationale why the 0.25 ML of 2 MG/ML lorazepam by mouth every twelve hours as needed for anxiety, was ordered for more than 14 days without a stop date.
Residents Affected - Some Review of Resident R2's care plan initiated on 11/9/22, identified focus due to antipsychotic medication use; goal - resident will remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbances, constipation/impaction, or cognitive/behavioral movement impairment through next review date; and interventions - monitor/record/report side effects and effectiveness. Continued review of Resident R2's care plan initiated 11/14/23, identified focus due to use of antianxiety medication; goal - resident will be free from discomfort or adverse reaction related to antianxiety therapy through next review; and interventions - monitor/document side effects and effectiveness. Continued review of Resident R2's care plan initiated 11/14/23, identified focus due to antidepressant medication use; goal - resident will be free from discomfort or adverse reactions related to antidepressant therapy through next review date; and interventions - monitor/document side effects and effectiveness. Review of Resident R2's clinical record failed to reveal any documented evidence that the facility was monitoring the effectiveness or adverse consequences of psychotropic medication use for antipsychotic, antianxiety, and antidepressant medications. During an interview on 4/18/25, at 10:45 a.m., the Director of Nursing (DON) confirmed that the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of three residents (Resident R2) reviewed. 28 Pa code 211.10(c) Resident care policies 28 Pa Code 211.5(f) Medical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0761
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to properly store medical supplies and biologicals in one of two medication rooms (second floor medication room) and two of four medication carts (first floor west and second floor west medication cart) failed to date open medications in two of four medication carts (first floor west and second floor west medication cart) and treatment medications were found unsecured at a resident's bedside for one of four residents (Resident R69).
Findings include: Review of the facility policy Medication Storage last reviewed 12/9/24, indicate it is the policy of this facility to ensure all medications housed on premises will be stored in the pharmacy and/or medication rooms according to the manufactures recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. External products disinfectants and drugs used for external use are stores separately from internal and injectable medications. Review of the facility policy Resident Self-Administration of Medications last reviewed 12/9/24, indicate bedside medication storage is permitted only when it does not present a risk to confused residents who wander into other resident's rooms. Review of Resident R69's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R69's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, indicated diagnoses of high blood pressure, anxiety and depression During an observation completed on 4/14/25, at 10:05 a.m. the following items were observed on Resident R69's bedside stand: 1 bottle iodine solution. 3 rolls of medical tape. 1 jar Silvadene cream. 2 bottles saline solution. 1 pair of scissors. During an interview completed on 4/14/25, at 10:09 a.m. Registered Nurse Employee E16 confirmed the above observations and removed items from the room and confirmed the facility failed to secure treatment medications. During an observation completed on 4/14/25, at 12:19 p.m. the second west medication cart contained
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0761
the following:
Level of Harm - Minimal harm or potential for actual harm
1 vial fluphenazine decanoate opened and without a date. 1 box lidocaine patches
Residents Affected - Few 1 jar Silvadene cream 1 Lantus insulin vial opened and not labeled with a date. 1 bottle amantadine opened and not labeled with a date. 1 bottle peridex rinse opened and not labeled with a date. During an interview completed on 4/14/25, at 12:46 p.m. Registered Nurse Employee E14 confirmed the above observations. During an observation on 4/15/25 at 10:03 a.m. of the second-floor medication room the following was discovered: Under sink the sink a drug disposal container and clear plastic bag. The refrigerator contained: 1 10ml bottle of sterile water opened without date. 1 2mg bottle of cathflo (a sterile solution used to restore function to a central venous access device) opened and without date. 1 envelope containing cash money. On the floor in the corner across from the refrigerator a gray plastic bag containing four pairs of shoes. During an interview completed on 4/15/25, at 10:18 a.m. Registered Nurse (RN) Employee E14 confirmed the above observations and that the facility failed to properly store medical supplies and biologicals in one of two medication rooms (second floor medication room) and two of four medication carts (second floor west medication cart). During an observation on 4/17/25, at 9:35 a.m. the first-floor west medication cart contained the following: 1 bottle Miralax bottle opened and not labeled with a date. 1 bottle timolol eye drops no name, opened and not labeled with a date. 1 bottle Ammonium Lactate 12% opened and not labeled with a date. 1 bottle Geri -Lanta opened and not labeled with a date.
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Page 44 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0761
1 bottle lactulose solution opened and not labeled with a date.
Level of Harm - Minimal harm or potential for actual harm
2 bottles Fluphenazine Hydrochloride opened and not labeled with a date. 1 vial Lantus insulin opened and not labeled with a date.
Residents Affected - Few 1 tube mupirocin ointment. 1 tube arthritis's relief cream. 1 tube triamcinolone cream. 2 boxes lidocaine patches 1 tube diclofenac sodium tube 1 can spring edition red bull beverage. During an interview completed on 4/17/25, at 9:43 a.m. Licensed Practical Nurse (LPN) Employee E15 confirmed the above observations and stated upon seeing the red bull beverage I would guess it is a staff members, I can't imagine a resident would drink it and confirmed that the facility failed to properly store medical supplies and biologicals in two of four medication carts (first floor west medication cart) 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0809
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility scheduled mealtimes, resident council group interview, and staff interviews it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including three of three residents sampled (Residents R73, R377, and R378), and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours.
Findings include: A review of facility policy Offering/Serving Bedtime Snacks, dated 12/9/24, indicates that it is the practice of the facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis. The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preference and requests on a daily basis. Intake of bedtime snack is documented in the medical record. A review of facility's Meal Times Dietary schedule provided revealed greater than 14 hours between dinner and breakfast: Dinner start time: 4:30 p.m.; Breakfast start time: 8:00 a.m., for a total 15.5 hours. - Dinner Cart 1 (first cart) arrives on unit at 4:45 p.m., Breakfast Cart 1 arrives on unit 8:15 a.m., for a total of 15.5 hours. - Dinner Cart 5 arrives (last cart) arrives on unit at 5:25 p.m., Breakfast Cart 5 arrives on unit at 8:55 a.m., for a total of 15.5 hours. During an interview on 4/15/25, at 11:00 a.m. two of six residents stated they infrequently were provided snacks. During an interview on 4/17/25, at 1:32 p.m., Dietary Manager Employee E11 confirmed that more than 14 hours elapse from the supper meal to breakfast the next day per the facility's scheduled mealtimes. During an interview on 4/15/25, at 2:47 p.m., the Nursing Home Administrator (NHA) confirmed that evening snacks are not documented unless a physician order has been placed in the EMR (Electronic Medical Record). Review of the admission record indicated Resident R73 was admitted to the facility on [DATE]. Review of Resident R73's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/4/25, indicated diagnoses of high blood pressure, diabetes mellitus (endocrine disease characterized by sustained high blood glucose levels), and osteomyelitis (an infection in the bone) of right ankle and foot. Review of R73's current physician orders failed to reveal an order for offering or providing an
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0809
evening snack.
Level of Harm - Minimal harm or potential for actual harm
Review of Resident R73's clinical record failed to indicate documentation that a nourishing evening snack was offered or provided.
Residents Affected - Some
Review of the admission record indicated Resident R377 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, dysphagia (difficulty swallowing foods, liquids, or both), and muscle weakness. Review of R377's current physician orders failed to reveal an order for offering or providing an evening snack. Review of Resident R377's clinical record failed to indicate documentation that a nourishing evening snack was offered or provided. Review of the admission record indicated Resident R378 was admitted to the facility on [DATE], with diagnoses that included cognitive social or emotional deficit following cerebral infarction (stroke related impairments leading to cognitive, social, and emotional deficits. These deficits can significant impact an individual's quality of life and their ability to function in daily activities), pulmonary disease, and dementia (group of symptoms affecting memory, thinking and social abilities). Review of R378's current physician orders failed to reveal an order for offering or providing an evening snack. Review of Resident R378's clinical record failed to indicate documentation that a nourishing evening snack was offered or provided. During a review of facility provided Resident Council Minutes since December 2024, failed to indicate resident group acceptance of a meal span greater than 14 hours. During an interview on 4/15/25, at 2:47 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including three of three residents sampled (Residents R73, R377, and R378), and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(3) Nursing Services 28 Pa. Code 211.12(d)(5) Nursing Services 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management
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Page 47 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for three of three residents (Resident R16 and R237).
Residents Affected - Some
Findings Include: Review of the facility policy Therapy Evaluation dated 12/9/24, stated the licensed therapist will perform an initial resident evaluation upon physician referral and any reevaluation where indicated. The Rehabilitation Department will be notified when a physician order is written for therapy evaluation and treatment. Review of the facility policy Therapy Treatment Procedures for Therapeutic Exercise dated 12/9/25, stated it is the facility's policy to provide therapy treatment procedures for therapeutic exercise as necessary. Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's care plan dated 1/2/25, indicated for therapy to evaluate and treat as ordered and as needed. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/7/25, indicated diagnoses of right below the knee amputation, diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and peripheral vascular disease (a slow and progressive disease that impacts the blood vessels in the body outside the heart.) Review of Resident R16's clinical record revealed occupational and physical therapy began on 1/7/25, with a frequency of 5x/week. Review of Resident R16's therapy Discharge summary dated [DATE], indicated the resident continues at long term care pending housing and prothesis. Review of Resident R16's active physician order dated 3/1/25, indicated to consult physiatry for prosthetic. During an interview on 4/14/25, at 2:23 p.m. Resident R16 stated I need a stump shrinker, I still don't have one. Review of Resident R16's clinical record on 4/17, 25, at 10:00 a.m. failed to include evidence the facility consulted physiatry for prosthetic as ordered. During an interview on 4/17/25, at 10:45 a.m. Physical Therapist, Employee E32 was asked what is the status of Resident R16 receiving a prosthetic and stated I am happy you are looking into it. I was just made aware two days ago, I am unsure how to obtain, told resident to call physician, it was indicated the physician did not want to talk to the resident. PT, Employee E32 was not aware how to obtain Resident R16's prosthetic.
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Page 48 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0825
Review of the clinical record indicated Resident R278 was admitted to the facility on [DATE].
Level of Harm - Minimal harm or potential for actual harm
Review of Resident R278's physician order dated 4/1/25, for physical therapy screen, evaluate, and treat as indicated.
Residents Affected - Some
Review of Resident R278's care plan dated 4/1/25, indicated to complete therapy as ordered. Review of Resident R278's physician note dated 4/3/25, indicated the resident had a below the knee amputation on 3/18/25, and is working with therapy to work toward shrinker and prosthetic. Review of Resident R278's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/7/25, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), acquired absence of right leg below knee, and insomnia (difficulty staying or falling asleep). Review of Resident R278's clinical record revealed physical therapy began on 4/8/25, seven days after admission. During an interview on 4/14/25, at 9:55 a.m. Resident R278 stated I came here for therapy and there was a delay in starting it. During an interview on 4/17/25, at 1:43 p.m. Director of Rehab, Employee E33 confirmed the facility failed to evaluate and treat Resident R16 timely. During an interview on 4/17/25, at 1:58 p.m. Director of Rehab, Employee E33 stated as far as i know, there hasn't been anything in process for Resident R278's stump shrinker. During an interview on 4/17/25, at 3:17 p.m. the Nursing Home Administrator and DON confirmed the facility failed to provide specialized rehabilitative services for three of three residents (Resident R16 R127, and R278). 28 Pa Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies.
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Page 49 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0850
Hire a qualified full-time social worker in a facility with more than 120 beds.
Level of Harm - Minimal harm or potential for actual harm
Based on review of clinical records and staff interview it was determined that the facility failed to employ a full time social worker.
Residents Affected - Some
Findings include: Review of clinical records for Resident R16, and Resident R128, Resident R278 clinical records indicated the NHA was completing social service documentation. During an interview on 4/17/25, at 3:28 p.m. confirmed that the facility did not have a fulltime social worker, and that the NHA has been filling in for the social worker. The facility has been without a social for approximately a month and that the facility failed to employ a full tie social worker to meet residents psychosocial needs. Refer to F699, F740, and F745. 28 Pa.Code: 211.16. (a) Social services.
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Page 50 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm or potential for actual harm
Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarters (April 2024 through June 2024 and July 2024 through December 2024).
Residents Affected - Some
Findings include: Review of facility policy Quality Assessment and Assurance Committee last reviewed 12/9/24, indicated the facility will maintain a QAA Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. The committee will be composed of the following staff at a minimum. -Director of Nursing -Medical Director or his/her designees -The Infection Preventionist -At least three other facility staff members, one of which will be the Administrator, owner, a board member, or other individual in a leadership role. The facility failed to have the QAPI Committee meeting sign-in sheets from the period of April 2024 through June 2024 available for review. A review of the QAPI Committee meeting sign-in sheets from the period of July 2024 through December 2024, did not reveal that the Infection Preventionist was in attendance. During an interview on 4/18/25, at 12:32 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to conduct QAA meetings at least quarterly with all of the required committee members as required. 28 Pa Code: 201.18(e )(1)(2) Management.
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Page 51 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for two of five residents (Resident R13 and R68), failed to prevent cross contamination during a dressing change for one of three residents (Resident R68), and failed to implement an infection control program that included a system of surveillance that included tracking, trending and mapping to identify possible communicable diseases or infections for one of six months (January 2025).
Residents Affected - Some
Findings include: Review of the facility policy Dressings, Dry/Clean, last reviewed 12/9/24, indicates the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the procedure include but are not inclusive to: -Clean bedside stand. Establish a clean field. -Place the equipment on the clean field -Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field -Wash and dry hands -Put on clean gloves -Cleanse wound -Discard items -Remove gloves, wash and dry hands -Apply the ordered dressing -Remove gloves, wash and dry hands -Clean bedside stand -Wash and dry hands Review of the facility policy Handwashing/Hand hygiene, last reviewed 12/9/24, indicates this facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection. Review of facility policy Care and Treatment of Feeding tubes last reviewed 12/9/24, indicates to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complication to the extent possible use infection control precautions and related techniques to minimize the risk of contamination. Review of the facility policy Isolation-Categories of Transmission Based Precautions last reviewed
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0880
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
12/9/24, indicates enhanced barrier precautions (EBP's) are utilized to prevent the spread of multi-drug-resistant organism (MDROs). EBP's are in place for residents with wounds and indwelling medical devices. EBP's remain in place for the duration of the residents stay. Review of Center for Disease (CDC) definition for Enhanced Barrier Precautions (EBP, a type of special isolation when providing direct care to a resident): The use of isolation gown and gloves during high-contact resident care activities including wound care. Review of the facility policy Infection Prevention and Control Program last reviewed 12/9/24, indicates a system of surveillance is utilized for prevention, identifying, reporting, investigation, and controlling infections for all residents, staff, volunteers, visitors and other individuals providing service. COVID-19 Testing: Anyone with even mild symptoms of COVID 19 should receive a test as soon as possible. Testing is recommended typically on day 1, day 3, and day 5 (day of exposure is day 0). The facility will have a plan to investigate and manage how contact tracing will be performed. Review of the facility policy Norovirus Prevention and Control, last reviewed 12/9/24, indicates the facility will implement strict infection control measures to prevent the transmission of the norovirus infection. Approaches for cohorting residents during the outbreak may include placing the resident in multi-occupancy rooms, or designated resident care areas or contiguous sections in the facility. Review of the facility policy Outbreak of Communicable Disease last reviewed 12/9/24, indicates outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. The Infection Preventionist (IP) and Director of Nursing (DON) shall be responsible for including but not inclusive to: Receiving surveillance information and tabulating data, maintaining a line list of identified cases and tracking. Review of Resident R13's clinical record indicates an admission date of 9/4/24. Review of Resident 13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, indicates the diagnosis of heart failure (heart can't pump the way it should), hypertension (high blood pressure), and diabetes (high sugar in the blood) Review of Resident R13's physician orders dated 4/8/25, revealed the resident was ordered Enhanced Barrier Precautions (EBP). Review of Resident R13's physician orders dated 1/10/25, indicated Tylenol Extra Strength Oral Tablet 500 milligrams (MG) Give 2 tablet via G-Tube (a flexible tube placed into the stomach to deliver nutrition or medication) three times a day for pain/discomfort. During a medication administration observation completed on 4/15/25, at 1:10 p.m. Registered Nurse (RN) Employee E13 entered resident R13's room. RN Employee E13 administered Resident R13's Tylenol as ordered. RN employee E13 did not utilize a gown as indicated by EBP signage on the door. During an interview completed on 4/15/25 at 1:13 p.m. RN Employee E13 confirmed not utilizing a gown during the medication administration via g-tube as required.
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Page 53 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0880
Review of Resident R68's clinical record indicates an admission date of 9/26/24.
Level of Harm - Minimal harm or potential for actual harm
Review of Resident R68's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/31/25, indicates the diagnosis of anemia (low iron in the blood), hypertension (high blood pressure) and diabetes (high sugar in the blood).
Residents Affected - Some Review of Resident R68's physician orders dated 3/26/25, indicates wound: cleanse left dorsal foot with Normal Saline Solution (NSS), pat dry, apply Medi honey to wound bed, apply oil emulsion dressing, cover with foam border dressing daily and as needed. Review of Resident R68's physician orders dated 4/6/25, indicate Enhanced Barrier precautions (EBP) related to due to wounds every shift. During an observation on 4/17/25, at 11:05 a.m. RN Employee E31 entered Resident R68's room to complete a dressing change. EBP signage was posted on the resident's door entrance. RN Employee E31 did not utilize a gown as indicated. RN Employee E31 placed the dressing supplies on the bed and applied gloves. Resident R68 requested a pad/barrier to be placed under her foot. RN employee E31 did not bring a barrier into the room, Resident R68 handed her a washcloth that was placed under her left foot. RN employee E31 the placed three paper towels on top of the washcloth and placed the heel of the left foot onto the paper towels. RN Employee E31 removed the soiled dressing, placing it into her glove, used another glove as a waste bag and placed onto the bed. Observation of wound revealed a piece of oil emulsion remained on the top surface of the wound. Resident R68 stated a package of the oil emulsion was in her bedside stand. RN Employee E31 retrieved the opened undated package and cut a small square, she removed her gloves and applied new gloves. RN Employee E31 placed the oil emulsion on top of the wound and applied the Medi honey on top of the oil emulsion by squeezing it directly from the tube, removed her gloves and placed new gloves prior to covering the area with a clean dressing. RN Employee E31 removed the paper towels that were under Resident R68's foot exited the room with the soiled supplies and placed all into the trash receptacle on the side of the treatment cart. She removed her gloves and indicated the treatment was completed. During an interview completed on 4/17/25, at 11:26 a.m. RN Employee E31 confirmed not establishing a clean field prior to dressing change, numerous opportunities for hand hygiene were missed. Utilizing undated opened treatment supplies from the bedside stand, dispensing the Medi honey directly onto the wound from the tube, utilizing a glove for her soiled discards and not following enhanced barrier precautions during the dressing change as required. Review of the facility provided Gastrointestinal complaints/Norovirus time line on 4/17/25, indicated that in January of 2025, 27 residents were noted to have had GI complaints. Review of the infection control tracking facility mapping for January 2025, did not include residents who were diagnosed with norovirus. During an interview completed on 4/17/25, at 1:56 p.m. Infection Preventionist (IP) RN Employee E18 confirmed that the residents who were diagnosed with the GI/norovirus in January of 2025, were not included on the infection control mapping. Upon further query IP RN Employee E18 also stated the facility has not kept tract of the residents or employees with signs or symptoms of COVID 19. Upon asking IP RN Employee E18 the process for Covid testing if indicated, she stated we would complete a test if negative no further testing would be needed, she was unable to provide information on testing guidelines and stated, we do what the CDC says to do and further commented Trump took down all the
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Page 54 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0880
stuff for the CDC guidance, it went away.
Level of Harm - Minimal harm or potential for actual harm
During an interview completed on 4/17/25, at 3:17 p.m. the Nursing Home Administrator confirmed that the facility failed to follow enhanced barrier precautions for two of five residents (Resident R13 and R68) failed to prevent cross contamination during a dressing change for one of three residents (Resident R68) and failed to implement an infection control program that included a system of surveillance tracking, trending and mapping to identify possible communicable diseases or infections for one of six months (January 2025).
Residents Affected - Some
28 Pa. code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.
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Page 55 of 60
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0882
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (Mid-October 2024, to 2/21/25).
Findings included: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP (infection preventionist) must work at least part-time at the facility, physically work onsite in the facility, have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field, cannot be an off-site consultant or perform the IP work at a separate location. During an interview on 4/17/25, at 1:56 p.m., the IP, Employee E18 stated, I can't tell you an exact start date, I would say sometime in January they combined the wound care position with infection control, the other nurse handed it to the Director of Nursing around mid-October, my certificate date is 2/21/25. During an interview on 4/17/25, at 3:17 p.m. the Nursing Home Administrator and Director of Nursing (DON) confirmed the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (Mid-October 2024, to 2/21/25). 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.
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Page 56 of 60
395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of five residents (Resident R13 and R60).
Residents Affected - Few
Findings include: Review of facility policy Influenza, Prevention and Control of Seasonal last reviewed 12/9/24, indicates this facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. All residents and staff are offered the vaccine prior to the onset of the influenza season. Review of the facility policy Pneumococcal Vaccine last reviewed 12/9/24, indicates all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, indicated diagnoses of high blood pressure, heart failure (heart doesn't pump the way it should) and chronic obstructive pulmonary disease (COPD-difficulty in breathing) MDS Section O- Special treatment, Procedures, and Programs O0250 indicated Influenza vaccine was coded 9- none of the above. O0300 indicated Pneumonia vaccine was coded a dash -. During a review of Resident R13's clinical record on 4/14/25, indicated that the Influenza and Pneumonia vaccination was not entered and was blank. Review of Resident R60's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R60's MDS dated [DATE], indicated the diagnosis of anemia (low iron in the blood), coronary artery disease (CAD- buildup of plaque in the hearts arteries) and anxiety. MDS Section OSpecial treatment, Procedures, and Programs O0250 indicated Influenza vaccine was coded 0- no reason 4-offered and declined. O0300 indicated Pneumonia vaccine was coded a 0- no reason 3-not offered. During a review of Resident R60's clinical record on 4/14/25, indicated that the Influenza and Pneumonia vaccination was not entered and was blank. During an interview completed on 4/17/25, at 1:56 p.m. upon asking Infection Preventionist (IP) Employee E18 the facility procedure for the influenza vaccine she replied I did not participate in it Upon inquiry concerning pneumococcal vaccine IP Employee E18 stated we don't try to get every immunization they missed further query concerning the immunizations for residents in the facility, IP Employee E18 replied we don ' t really have a process, we don ' t document of the refusal for
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0883
immunizations and confirmed that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of five residents (Resident 13 and R60).
Level of Harm - Minimal harm or potential for actual harm
28 Pa. Code 211.5(f) Clinical records
Residents Affected - Few
28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3) Nursing services.
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04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm or potential for actual harm
Based on observations and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition in the main kitchen and the facility failed to maintain essential equipment with a dryer not working ( 1 of 2 dryers).
Residents Affected - Few
Findings include: Review of Code of Federal Regulations §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. During an observation on 4/17/25, at 12:35 p.m., it was revealed that the main kitchens six well steam table (a type of commercial food service equipment that is used to keep foods at optimal serving temperatures) was operating with only three steam wells. During an interview on 4/17/25, at 1:32 p.m., Dietary Manager (DM) Employee E11 confirmed that only three of six steam table wells are functioning time of interview. Further interview revealed that DM Employee E11 was hired in December 2024, and at that time, 2 steam wells were broke and not functioning. DM Employee E11 stated that the third steam well just broke within the last few weeks. During an interview on 4/17/25, at 1:35 p.m., Dietary [NAME] Employee E12 revealed that he was hired nine months ago, and at that time 2 steam wells were broken and not functioning. Employee E12 stated that the third steam well just broke within the last month, and that back in October 2024, Maintenance was made aware of malfunctioning steam table, and service call from an outside food service equipment repair vendor was completed. Employee E12 stated that the vendor identified equipment parts needed to be ordered and replaced in order to fix the 2 broken wells. During an interview on 4/17/25, at 2:30 p.m., Maintenance Director (MD) Employee E13 confirmed that an outside food service equipment vendor came in and looked at the broken steam table wells in October 2024, and provided the facility with an invoice identifying parts needed and cost to repair. MD Employee E13 stated that this invoice for repair was provided to administration for payment. During an interview on 4/18/25, at 11:45 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to make certain that equipment was in safe operating condition in the main kitchen. During an observation on 4/16/25, at 11:31 a.m. one dryer was not working and the other dryer was in use in the laundry room. During an interview on 4/16/25, at 11:35 a.m. Laundry Assistant Employee E34 Stated the dryer is down, so we only have one dryer. During an interview on 4/17/25, 10:10 a.m. Director of Maintenance Employee E16 confirmed that the facility has a dryer down and the facility failed to maintain essential equipment. 28 Pa Code: 201.14(a) Responsibility of licensee.
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395666
04/18/2025
Spring Hill Rehabilitation and Nursing Center
2170 Rhine Street Pittsburgh, PA 15212
F 0943
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Based on review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for one out of five sampled records (Physical Therapist Employee E3).
Findings include: The facility Abuse, neglect, and misappropriation education policy reviewed 12/9/24, indicated to abuse, neglect, and misappropriation of resident funds education is completed upon hire and at least annually for all employees. Review of Physical Therapist Employee E3 personnel record indicated she was hired on 3/31/25. Facility punch detail report (Report indicating which days staff worked) dated 4/17/25, indicated that Physical Therapist Employee E3 worked at the facility for five days in April of 2025. Review of Physical Therapist Employee E3 personnel record did not include abuse training during her orientation to the facility. During an interview on 4/17/25, at 12:34 p.m. the Human Resources Employee E5 confirmed that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for Physical Therapist Employee E3 as required. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.
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Back to topCitations
30 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F620 - Admissions policy
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F710 - Physician Services
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F850 - Social worker
Hire a qualified full-time social worker in a facility with more than 120 beds.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
FAQ · About this visit
Common questions about this visit
What happened during the April 18, 2025 survey of SPRING HILL REHABILITATION AND NURSING CENTER?
This was a inspection survey of SPRING HILL REHABILITATION AND NURSING CENTER on April 18, 2025. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SPRING HILL REHABILITATION AND NURSING CENTER on April 18, 2025?
Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.